IJOPL Kavita Sachdeva, Tanvi Shrivastava 10.5005/jp-journals-10023-1151 ORIGINAL ARTICLE Dysphonia and its Correlation with Acoustic Voice Parameters 1Kavita Sachdeva, 2Tanvi Shrivastava ABSTRACT Source of support: Nil Aim: To evaluate the laryngeal causes of dysphonia, correla- Conflict of interest: None tion of acoustic voice analysis with Indirect laryngoscopic/ endoscopic findings in various voice disorders. AIM Study design: Hospital based prospective observational study. To evaluate the laryngeal causes of dysphonia and find a Materials and methods: Forty patients attending the ear nose correlation of acoustic voice analysis with indirect laryn- throat (ENT) outpatient department (OPD) at a Tertiary Care Government Hospital in one year, with dysphonia for more goscopic/endoscopic findings in various voice disorders. than 15 days were selected. History, examination, endoscopy, voice analysis was done. For consensus auditory-perceptual INTRODUCTION evaluation of voice (CAPE-V), the voice was analyzed under the following parameters: roughness, breathiness, strain, pitch, A voice disorder occurs when voice quality, pitch, and loudness, overall severity. Scores were given out of 100. For loudness differ or are inappropriate for an individual’s acoustic analysis, a computer-based software Praat was used age, gender, cultural background, or geographic location based on jitter, shimmer, noise-harmonic ratio and mean pitch. (Aronson and Bless; Boone, McFarlane, Von Berg, and Result: Benign lesions were most common in adults of age Zraik; Lee, Stemple, Glaze, and Kelchner). group 21 to 40 years, and malignancy in 41 to 50 years and 61 to 70 years; with male preponderance (4.7:1). Isolated vocal l Organic: Voice disorders that are physiological in cord palsy (32.5%) was the most common lesion presenting with nature and result from alterations in respiratory, dysphonia, followed by malignancy (25%). Out of benign lesions, laryngeal, or vocal tract mechanisms vocal polyp (10%) and nodule (10%) were the commonest, with q Structural: Organic voice disorders (OVD) that equal incidence. On analyzing the voice, jitter and shimmer were found to be important parameters depicting the perturbation in result from physical changes in the voice mecha- frequency and amplitude, respectively. These parameters, indi- nism (e.g., alterations in vocal fold tissues such as rectly, gave an idea about the vibratory motion of the vocal cords. edema or vocal nodules; structural changes in the On statistical analysis, jitter and shimmer showed significant direct correlation with the severity of dysphonia (jitter>shimmer). larynx due to aging) Noise to harmonic ratio (NHR) was raised in a significant q Neurogenic: Organic voice disorders (OVD) that number of dysphonic patients, with direct correlation with an result from problems with the central or periphe- increase in jitter. Although a significant relationship between the ral nervous system innervation to the larynx that variation in mean pitch and CAPE V could not be established in this study; instrumental analysis was still useful in documen- affect the functioning of the vocal mechanism (e.g., tation and quantification of mean pitch in various dysphonic vocal tremor, spasmodic dysphonia, or paralysis samples. of vocal folds) Conclusion: Acoustic measurement of voice is a simple yet l Functional: Voice disorders that result from the powerful tool to analyze the patients with dysphonic voice. improper or inefficient use of the vocal mechanism Keywords: Acoustic parameters, Consensus auditory-per- when the physical structure is normal (e.g., vocal ceptual evaluation of voice (CAPE-V), Dysphonia, Praat Voice fatigue; muscle tension dysphonia or aphonia; dip- analysis. lophonia; ventricular phonation) How to cite this article: Sachdeva K, Shrivastava T. Dyspho- nia and its Correlation with Acoustic Voice Parameters. Int J VOICE ANALYSIS Phonosurg Laryngol 2018;8(1):6-12. Subjective The CAPE-V uses continuous visual analog scales for 1Associate Professor, 2Senior Resident judgments of six parameters of voice: overall severity, 1,2Department of Ear, Nose and Throat, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India roughness, breathiness, strain, pitch, and loudness. Corresponding Author: Tanvi Shrivastava, Senior Resident, The perceptual evaluation of voice is considered to be an Department of Ear, Nose and Throat, Netaji Subhash Chandra essential aspect of the conventional voice diagnostics that Bose Medical College, Jabalpur, Madhya Pradesh, India, e-mail: is of primary relevance to most voice-disordered patients [email protected] and provides a global measure of vocal performance 6 IJOPL Dysphonia and its Correlation with Acoustic Voice Parameters readily available to all clinicians (Orlikoff, Dejonckere, MATERIALS AND METHODS Dembowski et al., 1999). Forty patients attending the ear, nose and throat (ENT) outpatient department (OPD), Netaji Subhash Chandra Instrumental/Objective Bose Medical College, Jabalpur, in 1 year, with dysphonia Using the computer-based software Praat, which is free for more than 15 days were selected. Patients who could and easy, it supports the clinician to rely on objective produce prolonged phonation for at least 3 seconds, were scientific data. It measures four basic parameters: selected (as required for voice analysis). Detailed history, general and ENT examination was done. Jitter, Shimmer, Harmonic to Noise Ratio, Pitch Indirect/direct laryngoscopy was done. Site, size, the Jitter refers to cycle-to-cycle, short-term perturbation in extent of the lesion (if present), laterality, the mobility of vocal cords were noted. A biopsy was taken, when the fundamental frequency of the voice. It is the relative required. evaluation of the very short-term variability of the pitch Subjective and objective voice analysis was done using within the analyzed voice sample. Jitter is one of the main CAPE-V and Praat respectively. measures for micro-instability in vocal fold vibrations. Voice was analyzed under the following parameters: Even tiny growths on vocal folds, such as polyps, may • Roughness influence frequency perturbation. According to the avail- • Breathiness able literature, jitter increases as control over laryngeal • Strain muscle tone becomes coarser or as the number of active • Pitch motor units decreases.1 • Loudness The shimmer is a cycle-to-cycle, short-term perturba- • Overall severity tion in the amplitude of voice. It increases with poor and Scores were given out of 100 inconsistent contact between the vocal fold edges. Stimuli given were: Incomplete closure of the glottis caused by polyp leads • Sustained vowels for 3 to 5 seconds each to an air leakage, which is acoustically characterized as • Reading noise. The NHR is the average ratio of the inharmonic • Spontaneous speech energy to the harmonic spectral energy. It includes con- tributions from both perturbations of amplitude and Additional Features 2 frequency. Tremor, pitch instability, diplophonia, falsetto, wet/ Epidemiologic studies of the prevalence and risk gurgly or other relevant terms. factors of voice disorders in the general population are relatively rare. Moreover, the small numbers of studies Objective Analysis that exist are characterized by substantial variability A computer-based software Praat was used. The voice in reported prevalence estimates, ranging from 0.65% samples were analyzed quantitatively based on: to 29.9% in the general population.3,4 In spite of high • Jitter prevalence, in most government-run hospitals in India, • Shimmer just an auditory perception of voice [CAPE-V or grade, • Noise-harmonic ratio roughness, breathiness, asthenia, strain (GRBAS)] is done • Mean pitch without any quantification of the auditory data. This lack The normative values vary according to the software. of standard voice measure compromises the evaluation Normative for Praat are as follows: of different treatments and their outcomes and becomes Jitter: ≤ 1.040 % particularly important in this day of medical liability. To Shimmer: ≥ 3.810 % effectively evaluate their outcome a quantitative measure NHR: < 1 of voice function providing relevant information is Adult males Adult females needed. So an attempt has been made to study and assess Mean pitch: 128 Hz 225 Hz the quantitative parameters of voice using the software Minimum pitch: 85 Hz 155 Hz Praat, concerning various disorders and to highlight its Maximum pitch: 196 Hz 334 Hz implication in the present scenario. Voice therapy was given to these patients and was kept on follow-up. STUDY DESIGN Lesions which did not respond to voice therapy were Hospital based prospective observational study. subjected to MLS. International Journal of Phonosurgery and Laryngology, January-June 2018;8(1):6-12 7 Kavita Sachdeva, Tanvi Shrivastava RESULT Table 1: Occupation wise distribution Age Group Occupation Frequency Percent (%) Army 1 2.5 • Voice disorders were found in a wide age group of Asha worker 1 2.5 15 to 80 years. Benign lesions were most common in Bidi maker 1 2.5 adults of age group 21 to 40 years. Malignant lesions Farmer 12 30 were more commonly seen in the age group of 41 to House wife 3 7.5 50 years and 61 to 70 years. Labour 9 22.5 Mechanic 1 2.5 Sex Rickshaw driver 1 2.5 • Males were more commonly affected than females Student 5 12.5 in benign as well as malignant lesions with a ratio Security guard 1 2.5 of 4.7:1. Functional dysphonia with hoarseness was Singer 1 2.5 more commonly seen in females (Graph